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Stomach Cancer
Incidence Stomach (gastric) cancer is an adenocarcinoma of the stomach wall. The rate of stomach (particularly distal) cancer has been steadily declining in the United States. However, cancer of the cardia and the gastroesophageal junction is increasing. Gastric cancer still accounts for more than 10,540 deaths and 21,320 new cancer cases annually. Asian Americans and Pacific Islanders, Hispanics, and African Americans have higher rates of stomach cancer than non-Hispanic whites. Stomach cancer is more prevalent in men of the lower socioeconomic class, primarily those living in urban areas. The incidence of stomach cancer increases with age, with the majority being diagnosed between 65 and 80. At the time of diagnosis, only 10% to 20% of patients have disease confined to the stomach, and more than 50% have advanced metastatic disease. The 5-year survival rate is 80% in patients with early stages (confined to the stomach) and less than 30% in those with advanced disease Risk Factors * Age (the majority of those being diagnosed are between the ages of 65 and 80) * low socioeconomic status * Gender (stomach cancer is more common in men than in women) * Race (Asian Americans, Pacific Islanders, Hispanics, and African Americans) * Occupation (workers in the coal, metal, and rubber industries) * H. pylori infection * Stomach lymphoma * A diet consisting of large amounts of smoked foods, salted fish and meat, and pickled vegetables (foods containing nitrates and nitrites) * Smoking * Obesity * Previous stomach surgery * Pernicious anemia (decrease in RBCs due to inability to properly absorb vitamin B12) * Type A blood * Family History * Stomach polyps * Ebstein-Barr Virus (EBV) infection Signs and Symptoms * No desire to eat (poor appetite) * Weight loss (without trying) * Pain or just vague discomfort in the belly * A sense of fullness after eating a small meal * Heartburn or indigestion * Nausea * Vomiting, with or without blood * Swelling in the abdomen * Low red blood cell counts (anemia) which can cause you to feel tired or short of breath with just walking Of course, many of these can be caused by problems other than cancer. But if you have any of these problems and they get worse or don’t go away, you should see a doctor so the cause can be found and treated. How is it diagnosed? Upper GI endoscopy is the best diagnostic tool. Biopsy of the tissue and subsequent histologic examination are important for the diagnosis of stomach cancer. Endoscopic ultrasound, CT, and PET scanning can be used to stage the disease. Barium studies do not always detect small lesions of the cardia and the funds. Laparoscopy is done to determine peritoneal spread. Other diagnostic tools include exfoliative cytologic studies, CBC, urinalysis, stool examination, liver enzymes, serum amylase, and the presence of the tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen (CA), and alpha-Fetoprotein. Medical Treatments The main treatments for stomach cancer are: * Surgery * Chemotherapy * Targeted therapy (trastuzmab Herceptin and ramucirumab Cyramza) * Radiation therapy Often the best approach uses 2 or more of these treatment methods. The 3 main types of surgery for stomach cancer: * Endoscopic resection: Resection refers to cutting out a tumor or part of an organ. In this operation, the cancer is removed through an endoscope (a long, flexible tube passed down the throat and into the stomach). This can be done only for some very early cancers where the chance of spread is very low. * Subtotal (partial) gastrectomy: With this approach only part of the stomach is removed, sometimes along with part of the esophagus or the first part of the small intestine. Nearby lymph nodes are also removed, sometimes along with other nearby organs. Eating is much easier after surgery when only part of the stomach removed. This may be an option if the cancer is only in the lower part of the stomach close to the intestines. It is also sometimes used for cancers that are only in the upper part of the stomach. * Total gastrectomy: In this operation, the surgeon removes all of the stomach. The nearby lymph nodes are removed, and sometimes also the spleen and parts of the esophagus, intestines, pancreas, and other nearby organs. The end of the esophagus is then attached to part of the small intestine. People who have had a total gastrectomy can only eat a small amount of food at a time. Because of this, they must eat more often. This method is used if the cancer has spread throughout the stomach. It is also often used if the cancer is in the upper part of the stomach. Chemotherapy (chemo) is the use of drugs to kill cancer cells. Usually the drugs are given into a vein or taken by mouth as pills. Once the drugs enter the bloodstream, they go throughout the body. Chemo is useful in treating cancer that has spread beyond where it started. Chemo can be given before surgery. It may shrink the tumor and make it easier to take it out and help patients live longer. For some stages of stomach cancer, this is one of the standard treatment options. Chemo may also be given after surgery. It is used to kill any groups of cancer cells that may have been left behind but are too small to be seen. The goal is to keep the cancer from coming back. For stomach cancer, chemo is often given along with radiation after surgery. Chemo may also be used as the main treatment for stomach cancer that has spread to distant organs. It may help relieve symptoms for some patients, especially those with spread to other parts of the body. It may also help some patients live longer. Chemotherapy (chemo) drugs target cells that divide quickly, which is why they often work against cancer cells. But there are other aspects of cancer cells that make them different from normal cells. In recent years, researchers have developed new drugs to try to target these differences. These drugs tend to have different side effects than standard chemo drugs. * Trastuzumab targets a certain protein called HER2. If the stomach cancer cells have too much HER2 protein, giving this drug with chemo can help some patients with advanced stomach cancer live longer than giving chemo alone. Not all stomach cancers have too much HER2 protein, so your cancer has to be tested to see if this drug can help. * Ramucirumab (Cyramza) is a targeted therapy drug that works by helping to stop new blood vessels from being formed. This can help prevent the growth and spread of cancers like stomach cancer. This drug is used only for advanced stomach cancer. Radiation treatment is the use of high-energy rays (such as x-rays) to kill cancer cells or shrink tumors. Before surgery, radiation can be used along with chemo to try to shrink some tumors to make surgery easier. After surgery, radiation can be used to kill very small areas of cancer that cannot be seen and removed during surgery. Radiation, especially when combined with chemotherapy (chemo), might delay or prevent the cancer from coming back after surgery and may help people to live longer. Radiation can also be used to slow the growth and ease symptoms of advanced stomach cancer such as pain, bleeding, and trouble eating. Nursing Management (Nursing Process) Provide emotional and physical support, provide information, clarify test results, and maintain a positive attitude with respect to the patient’s immediate recovery and long-term survival. Promote a positive nutritional state, as stomach cancer can lead to changes and appetite and early satiety, which can lead to a poor nutritional status. Provide several small meals a day, rather than three regular meals. Supplement the patient’s diet with liquid supplements and vitamins. If prescribed, feed the patient through enteral feedings or TPN. If a blood transfusion is necessary, observe for reactions to the transfusions and monitor hemoglobin and hematocrit levels. Following surgery, monitor the patient for signs of dumping syndrome (generalized weakness, sweating, palpitations, dizziness, abdominal cramps, hyperactive bowel sounds), postprandial hypoglycemia (sweating, weakness, confusion, palpitations, tachycardia, anxiety), and bile reflux gastritis (epigastric distress that increases after meals, vomiting). If a total gastrectomy is required, following surgery, monitor the patient for signs of leakage of fluids at the anastomosis site as evidenced by an elevation in the temperature and increasing dyspnea. Provide analgesics for management of pain. Provide the patient with a list of community agencies (e.g., American Cancer Society) that are available for assistance before the patient goes home.